Impact of the COVID‐19 pandemic on Pennsylvania and its healthcare system

Abstract Background and Aims Coronavirus disease 2019 (COVID‐19) has taken a toll on Pennsylvania, and the fight against the pandemic continues, with the commonwealth's hospitals and health systems at the epicenter. This report aims to demonstrate the magnitude of the impact of the pandemic on Pennsylvania, with specific attention to its hospitals and health systems and their financial status during the very first year of the pandemic. Methods To measure this magnitude, publicly available US and Pennsylvania COVID‐19 data is analyzed, including more detailed geographical, rural/urban, and race/ethnicity analyses. Results The results show that the case counts started with just two cases on March 6, 2020, and rose to approximately a million by the first anniversary of the pandemic's arrival in the commonwealth. Tragically, the death toll totaled nearly 25,000 during the first year. Philadelphia County had the highest number of total COVID‐19 cases, while Forest County had the highest incidence rate. The Southeast region had the highest number of total COVID‐19 cases, while the Lehigh Valley had the highest incidence rate. The incidence rate also was higher in rural counties than in urban counties. Black and Latino/a/x populations of Pennsylvania were disproportionally affected by the virus. Several reports measured the financial impact of the pandemic on the state's hospitals to be $4.1–$5 billion during this year. Conclusion Hospitals are economic anchors of their communities. To fulfill their critical mission during the pandemic and beyond—and remain economic and community anchors—they need ongoing state and federal support.

These COVID-19 preparations and precautions came at a great financial cost to hospitals. Revenue shortfalls-due to state and federal government orders requiring hospitals to defer or cancel scheduled services and procedures to free up capacity for COVID-19 patients-intensified these burdens. In 2020, between increased costs and revenue losses, Pennsylvania hospitals incurred an estimated $5 billion shortfall. 6 In 2020, hospitals learned a great deal about how to coexist with COVID-19. They put in place protocols to treat existing COVID-19 patients, and also safely provide important routine and specialty care.
Through reconfiguring space to accommodate for social distancing, creating special wings for COVID-19 patients, and doubling down on infection prevention and cleaning best practices, hospitals have been able to implement a model for safe care for all who need it.
Hospitals are economic anchors of their communities. Pennsylvania's hospitals and health systems contributed $143 billion in spending including $37 billion in salaries and supported more than 660,000 jobs during the fiscal year (FY) 2019. 7 Hospitals will need long-term federal and state support to ensure they can remain economic and healthcare leaders for their communities.
This report aims to summarize how COVID-19 affected Pennsylvania, with specific attention to its hospitals and health systems.

| Case history in Pennsylvania
Pennsylvania recorded its first confirmed case of COVID-19 on March 6, 2020, and the total number of cases quickly rose as the testing increased and the virus spread. The rate of increase in COVID-19 cases slowed during May and June 2020, as compared to April ( Figure 1). As the second wave of the pandemic hit Pennsylvania at the beginning of October 2020, the total number of cases started to increase even more dramatically than it did for the first wave. By the end of January 2021, the rate of increase slowed. As of March 6, 2021-exactly 1 year after the first confirmed case in the state-948,861 Pennsylvanians had either confirmed or probable cases of COVID- 19. 4 As seen in Figure 2, since the onset of COVID-19, Pennsylvania has seen two notable spikes and one smaller rise in daily case counts. On April 8, 2020, the case count peaked at 2058 cases per day. Another rise in cases occurred during the summer months with a peak of 1207 cases on July 23, 2020. Pennsylvania experienced rapidly increasing case numbers at the start of the second wave. On December 10, 2020,

| COVID-19 in Pennsylvania's counties and regions
The pandemic followed different trends throughout the commonwealth. This section includes the results of county-based and regional analyses of the total number of COVID-19 cases and COVID-19 incidence rate per 100,000 population.
During the COVID-19 pandemic, all 67 counties in Pennsylvania have had residents that tested positive for the coronavirus. Figure 4 shows how the cases were distributed throughout the commonwealth.
The darker shaded areas indicate a higher number of total cases, which accumulated around urban areas (Philadelphia and Allegheny counties).  Contrary to the trend of the total number of cases by county, COVID-19 incidence rates were higher for rural counties.  Altoona/Johnstown regions (darker shaded areas) had incidence rates that are higher than 8000 cases/100,000 population, which are followed by South Central, Northwest, and Southeast regions with incidence rates between 7000 and 8000 cases/100,000 population.
Southwest and Northeast regions had the lowest rates that are smaller than 7000 cases/100,000 population. 4

| COVID-19 incidence in rural and urban Pennsylvania
According to the Centers for Disease Control and Prevention's (CDC) analysis of COVID-19 incidence by urban-rural classification, nationally, large central and large fringe metropolitan areas had the highest COVID-19 incidence early in the pandemic (mid-March to mid-May). However, since September 2020, COVID-19 started spreading into rural communities faster, resulting in the highest incidence in medium/small metropolitan areas and micropolitan/noncore areas until November 2020 † . 9 The rural population consists of 26% of Pennsylvania's total population, which makes the commonwealth the state with the thirdlargest rural population. 10,11 When we look at this crucial piece of Pennsylvania's overall population, rural counties in Pennsylvania had a higher overall incidence rate than its urban counties based on the number of total cases between March 6, 2020, and March 6, 2021 ( Figure 8). The trend observed in Pennsylvania was similar to the nationwide trend of rural communities having higher overall rates during the later phases of the pandemic.  The missing data and change in the data on July 30, 2020, is due to a change in the criteria for reporting COVID-19-related deaths § . 123

| Rate of COVID-19 patients to other inpatients
As seen in Figure 10, at the end of July 2020, 7  As cases began to rise in the state, the deaths also increased. As seen in Figure 12, during the first spike in COVID-19 cases, the worst day was April 25, 2020, with 184 deaths. The daily recorded deaths due to COVID-19 remained consistent between the first and the second waves but started to increase dramatically by the end of October 2020.
The second wave peaked with the most single-day deaths reaching 238 In consultation with the Pennsylvania Department of Health, the state has been updating the mitigation efforts based on the spread of the pandemic. Below is a timeline ( Figure 16) and a table (  The pandemic has changed dynamics within the healthcare workforce, due to healthcare workers being unable to work because of illness or exposure to COVID-19, deciding to retire early, taking leaves of absen ce out of increased health risk concerns, facing the stress and emotional strain of the pandemic, or experiencing difficulty securing child care. • Expended $349 million for increased staffing and labor costs to expand services and staff emergency operations centers.
• Devoted $258 million to purchase additional supplies and equipment, such as personal protective equipment, computer hardware, and temporary tents.
• Incurred $21 million in costs to set up emergency operation centers, including construction and retrofitting facilities to provide separate screening and security areas. The report's key findings include: • Under an optimistic scenario, US hospitals could face a total revenue loss of $53 billion during 2021-including $27 billion in outpatient revenue, $17 billion in inpatient revenue, and $9 billion in emergency department revenue.
• Under a pessimistic scenario, US hospitals could face a total revenue loss of $122 billion during 2021-including $64 billion in outpatient revenue, $41 billion in inpatient revenue, and $17 billion in emergency department revenue.
• Hospitals experienced increased expenses, in addition to revenue losses. During 2020, hospitals reported a 17% increase in drug expenses, a 16% increase in purchased service expenses, a 14% increase in labor expenses, and a 13% increase in supply expensesall of which could continue into 2021 as the pandemic continues.  For hospitals to fulfill their critical mission during the pandemic and beyond-and remain economic and community anchors-they need ongoing state and federal support. In 2021, hospitals will need these resources as they deliver outstanding care and administer the COVID-19 vaccine to patients across the commonwealth.
With the identification of the disparities and challenges COVID has presented before us, efforts and resources could be more efficiently targeted and focused on addressing them. Moving forward, we encourage improvements in health information exchange (HIE) to improve coordinated and timely care between different healthcare providers, public health, and other stakeholders.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The authors confirm that the data supporting the findings of this